Provider Demographics
NPI:1760880173
Name:KELLY, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4833 BETHESDA AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-5244
Mailing Address - Country:US
Mailing Address - Phone:301-657-3220
Mailing Address - Fax:
Practice Address - Street 1:4833 BETHESDA AVE STE 302
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-5244
Practice Address - Country:US
Practice Address - Phone:301-657-3220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD9294122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist